Mirizzi syndrome: report of a case and the challenge of management in our environment.

BACKGROUND: Mirizzi Syndrome is a rare complication of cholelithiasis reported to occur in 1% of all patients with gall stones and an incidence of 0.7-1.4% in all cholecystectomies. It is characterized by an impaction of a large calculus in the Hartman's pouch of the gall bladder (GB) or in the cystic duct, causing an extrinsic obstruction of the common hepatic duct. This can, with time, result in varying degrees of fistula formation between the duct and the GB. Types I, IIa, b and c have been described depending on the circumference of the duct involved in the cholecysto-choledochal fistula. This syndrome presents clinically as surgical jaundice. The preoperative diagnosis is difficult as well as the surgical management of the type II subtypes. The aim of this paper is to draw attention to this clinicopathological entity as it occurs with the same frequency in our environment as in the environment with high incidence of cholelithiasis. METHOD: We report a case in our practice (Mirizzi Type IIa) and discuss the difficulties encountered in pre-operative diagnosis and subsequent management. The literature is also reviewed RESULTS: The diagnosis of Type IIa Syndrome was made on the operating table. The on-table cholangiogram was inconclusive. A choledochoplasty was performed over a T-tube and this was removed after 12 weeks. Patient has done well thereafter. CONCLUSION: The local surgeon is advised to have a high index of suspicion about this condition so as not to be caught unawares.

Cranial computed tomographic findings in Nigerian women with metastatic breast cancer.

INTRODUCTION: Brain metastases (BM) occur in up to one-fifth of patients with metastatic breast cancer (MBC). Imaging plays a key role in diagnosis. The pattern and distribution of these changes are also crucial to their management. These patterns have not been fully studied in Nigerian women. MATERIALS AND METHODS: Retrospective analysis of the findings on the cranial Computed Tomography (CT) scans performed in 59 breast cancer patients with suspected BM treated at the University Teaching Hospital in Ibadan, between 2005 and 2010. The imaging features were evaluated in relation to their clinical characteristics. RESULTS: In the 59 patients studied (mean age 50.9 years ± 11.75 SD), headache (40.7%) and hemiparesis/hemiplegia (16.9%) were the commonest clinical presentation. Lytic skull lesions were seen in 15 patients (25.4%), most commonly in the parietal bones. Thirty-nine patients (66.1%), had parenchymal brain lesions, and only 8 (20.5%) of these were single lesions. Most of the lesions were isodense (19/39; 51.4%) the parietal lobe was the most common site with 50.8% (30/59) occurrence and the leptomeninges the least with 13.6% (8/59). Orbital or sellar region involvement occurred in only two patients. The size of the lesions, was <2 cm in 17 (28.8%), 2-5 cm in 14 (23.7%) and >5 cm in 5 patients. Sixteen (27.1%) patients were free of any lesion either in the skull or brain. Patient presenting with multiple brain lesions were more likely to have skull lesions though this was not statistically significant (P = 0.584). CONCLUSION: The brain continues to be a sanctuary site for breast cancer metastases and CT imaging remains an invaluable tool in the clinical evaluation and therapeutic management of Nigerian women with BM from MBC. It also appears that the demographic and imaging findings in these patients are similar to other racial groups.

Preliminary experience with laparoscopic cholecystectomy in a nigerian teaching hospital.

BACKGROUND: Presently many centers have facilities for laparoscopic surgery in Nigeria, but the practice is just evolving in most of these centers. This article presents the preliminary experience of the endoscopic surgery unit (general surgery) at the University College Hospital Ibadan Nigeria. The University College Hospital is the premier Nigerian teaching hospital and is located in the south-western part of the country. METHODS: All the patients who had laparoscopic cholecystectomy at the University College Hospital between June 2009 and January 2011 were included in this study. The patients' demographic data, diagnosis, results of investigations and intra-operative findings were obtained from the records. Additional information extracted from the records was the duration of surgery, complications, outcome and discharge periods. RESULTS: There were thirteen patients over the twenty month period consisting of twelve females and one male. The age range was twenty six to sixty seven years with a mean of 44.6 years. The duration of surgery ranged from 90 to 189 minutes with a mean of 124 minutes. There were two complications. These were adhesive bowel obstruction and common bile duct injury. The duration of admission ranged from four to thirty two days with a mean of 7.53SD ± 8.5 days. There was one conversion to open surgery due to intra-operative gallbladder perforation with consequent dispersal of multiple gall stones within the peritoneal cavity. The common bile duct injury was diagnosed four days following surgery for which a choledochojejunostomy was done after initial conservative treatment. There was no mortality. CONCLUSION: Laparoscopic surgery is feasible in Nigeria and is likely to show increasing popularity among patients and surgeons. A careful patient selection protocol is necessary for an acceptable success rate with minimal complications. Our protocol of patient selection eliminated the need for intra-operative common bile duct exploration which requires expensive instruments. However, to sustain laparoscopic surgery it is pertinent to ensure an activity based costing system which will not make it arbitrarily too expensive for the general population.

The challenges and solutions of laparoscopic surgical practice in the developing countries.

Laparoscopic surgery has become the preferred standard in developed countries. New procedures in laparoscopic surgery are continually being developed. Despite these innovations Nigeria and many other African are yet to fully embrace this surgical approach. Few therapeutic laparoscopic surgery procedures are performed annually in Nigerian teaching hospitals. Appropriate personnel and the initial high cost of acquiring state of the art equipments are some of the challenges in laparoscopic surgery in developing countries. A few centres have developed ways of solving these challenges. We discuss the envisaged problems with laparoscopic surgery in Nigeria and some other African countries and suggest solutions to these problems.

Review of fine needle aspiration cytology in the management of goitres in Ibadan, Nigeria.

OBJECTIVE: The use of Fine Needle Aspiration Cytology (FNAC) in the investigation of goitres was introduced into our practice more than a decade ago. This is a review of its diagnostic accuracy for thyroid carcinoma seven years after the first evaluation and following the establishment of the 'FNAC Clinic'. METHOD: This is a retrospective study of patients who had FNAC of goitres and the histopathology of their thyroidectomy specimens between 1995 and 2004. The accuracy of the cytology reports were evaluated against the histology reports. The turnaround time of the patients for surgery was also determined. RESULTS: There were 130 females and 21 males with an age range of 7-86 years. The diagnostic accuracy of the procedure for carcinoma was 89% with a sensitivity of 35%, specificity of 97%, positive predictive value of 64%, and a negative predictive value of 91%. The average turnaround time for surgery was 178.7 +/- 248.7 days with a range of five days to three and a half years. CONCLUSION: The diagnostic accuracy of FNAC of goitre for carcinoma improved in the period under review. However, the long surgery turnaround time may reduce the usefulness of the procedure. The accuracy may be improved further by a protocol of ultrasound guidance, capillary collection with no-aspiration technique, on-site review of slides with a repeat of FNA as necessary.

Bile duct stricture -- a sign of things to come?

OBJECTIVE: The aim of the report is to highlight this difficult to-treat condition hitherto uncommon in our environment and warn of the likelihood of more to come with the rising incidence of gallstone in our sub region. PATIENT AND METHOD: A case report of an 18-year-old male undergraduate patient. RESULT: A successful management with clinical, biochemical and radiological evidence (OTC and tubograms) despite inadequate investigative tool. PRINCIPAL CONCLUSION: With the rising incidence of gall stones in our environment, it is imperative that the Trainee Surgeon must be schooled in common biliary surgery and help prevent this dreaded complication (bile duct stricture) and other sequelae of gall bladder surgery. A plea is also made for the provision of essential investigative tool to facilitate management of such cases in recognised centers.

Familial thyrotoxicocis in five Nigerians.

We describe the occurrence of thyrotoxicosis in four Nigerian families. Hitherto. the descriptions of familial thyrotoxicosis have been confined to the Caucasian population and only recently in a Chinese family. This is the first description of familial thyrotoxicosis in the Nigerian population. The mutation analysis of the genomic DNA of the TSH receptor of these patients is required to define the genetic mutations that caused the disease. We recommend that a high index of suspicion for familial thyrotoxicosis should be exercised in the clinical evaluation of patients who present with hyperthyroidism.

Necrotizing fasciitis.

Necrotizing fasciitis (NF) is a rare but rapidly progressive and potentially fatal disease condition. It is characterized by progressive inflammation and extensive necrosis of the subcutaneous tissue and fascia, sparing the underlying tissue. It is a poly-bacterial infection and is associated with profound systemic toxicity, considerable morbidity and a high mortality rate. The outcome is influenced by early recognition and radical surgical debridement. We present a report of six cases of NF who presented to our surgical service within the past 5 years.

A review of gall bladder carcinoma in Ibadan.

Twenty cases of histologically proven carcinoma of the gall bladder (GB) seen in the University College Hospital, Ibadan, Nigeria between 1983 and 1997 were reviewed. There were seven males and thirteen females, thus giving a sex ratio of 1:2. The majority of the cancers occurred between the fourth and seventh decade of life. The pre-operative diagnosis has improved and about 70% of the ten patients with adequate clinical information had definitive surgical treatment. The advent of new imaging techniques at this hospital, consisting of ultasound (US) and computerized axial tomography(CT) has made pre-operative diagnosis possible. This is in contrast to the situation noted twenty years earlier in a similar study. Surgical intervention can now be timed and planned appropriately in the majority of cases although late presentation is still a problem. With earlier presentation, prompt diagnosis and appropriately planned surgery, a better survival figure is anticipated at this institution.

Cholelithiasis in Ibadan: an update.

This study is to ascertain the present status of cholelithiasis in our environment. Six hundred and seventy (670) consecutive abdominal, ultrasounds done for various abdominal complaints at the University College HospitaL Ibadan from January 1977 to December 1998 were studied for gall stones in addition to other studies of the abdomen. Only twelve (12) gallstones were found, giving a prevalence of 1.79%. Only 25% were silent stones. The male:female ratio was 1:3. The mean age was 30 years (S.D = 2.8) and peak age was between 30 and 40 years. The average body mass index (B.M.I) was 23.49 kg/m2 (S.D = 3.9). The average parity among the women was four (4). Only one ultrasound was false (false negative). This study shows an increase. In prevalence over previous figures (1.79%) as against 0.007% in the sixties). The peak age is a decade lower and the anthropometric measurements in our patients do not support the typical caucassian model.

Spontaneous rupture of incisional hernia--a case report.

A case of spontaneous rupture of an incisional hernia is hereby presented. Though very rare in adults, it is a potentially fatal but preventable clinical condition.

Colorectal carcinoma in Ibadan, Nigeria: a 20-year survey--1971 to 1990.

BACKGROUND/AIMS: Five hundred and four (504) cases of histologically proven adenocarcinoma of the large bowel were seen in the University College Hospital, Ibadan, between 1971 and 1990. The rise in incidence predicted by the writers in the seventies is confirmed but it is feared that the economic depression may make alternative medicine attractive and turn patients away from the hospitals. The sex ratio has approached that seen in the West but the average age incidence has not changed. METHODOLOGY: One hundred and forty-one (141) case notes were available for critical evaluation. RESULTS: These case notes show that patients still present rather late and some still find the idea of terminal colostomy sufficiently repugnant to refuse surgery. This disease is no respecter of persons and the clinical features are in no way different from those already recorded. Most of the colonic tumors are located on the right side of the colon. This has been the pattern in the African population--a phenomenon now reported frequently in the West. CONCLUSIONS: The colon/rectum ratio has been reversed in favor of the rectum but unfortunately, this has not had a positive influence in early presentation and diagnosis. The "silent majority" on the right side of the colon can only add to the problem of late presentation. A plea is, therefore, made for adeq-uate investigations of 40 years old and above presenting with vague pain in the right iliac fossa and/or features of hemorrhoids which may herald carcinoma on the right and left, respectively.

Prevalence of gall stones in a group of antenatal women in Ibadan, Nigeria.

The prevalence of gall stones in Africa is low even though this varies from one part of the continent to another. The few studies were hospital based and excluded majority of silent stones. Abdominal ultrasounds were carried out prospectively on 4,214 consecutive patients referred to an ultrasound centre which cares primarily for pregnant women--a well known vulnerable group for gall stones. An overall prevalence rate of 2.1% was found. This represents a 300-fold increase over previous figures in Ibadan albeit from a different study group. A further study of the disease in the general population is necessary, though it is suggested that the figure in the general population may be less. When this figure is compared with the 10 to 20% in Europe and North America, it confirms the low incidence of the disease in our environment. Majority of the stones were asymptomatic (95%). This needs to be confirmed in the general population. The average stone former in our environment as in previous study does not conform to the classical caucassian description.